Citation Nr: 18144808 Decision Date: 10/25/18 Archive Date: 10/25/18 DOCKET NO. 11-12 628 DATE: October 25, 2018 ORDER Entitlement to service connection for a cardiovascular disorder as due to herbicide exposure is granted. Entitlement to service connection for a renal disorder as secondary to diabetes mellitus, type II is granted. REMANDED Entitlement to service connection for a visual disorder, to include as secondary to diabetes mellitus, type II is remanded. FINDINGS OF FACT 1. The Veteran served in the Republic of Vietnam and is presumed to have been exposed to herbicide agents. 2. The Veteran’s cardiovascular disorder is presumed to be related to his herbicide exposure while in Vietnam. 3. Resolving doubt in the Veteran’s favor, his renal disorder is related to his service-connected diabetes mellitus, type II. CONCLUSIONS OF LAW 1. The criteria for service connection for a cardiovascular disorder are met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.307, 3.309(e). 2. The criteria for secondary service connection for a renal disorder are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1961 to February 1969, to include service in the Republic of Vietnam. The Veteran passed away in June 2012. The Appellant was properly substituted for the Veteran in October 2013. This matter comes before the Board on appeal from a December 2013 rating decision of the Department of Veterans Affairs (VA) Philadelphia Pension Center in Philadelphia, Pennsylvania. A hearing was held in June 2014 before the undersigned Veterans Law Judge. The Board remanded the appeal for further development in October 2014 and December 2017. Service Connection Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if preexisting such service, was aggravated thereby. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). Generally, to establish entitlement to service connection, a veteran must show evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a causal relationship between the current disability and an in-service injury or disease. All three elements must be proved. See generally Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). If a Veteran was exposed to herbicides during active military, naval, or air service, certain diseases shall be service-connected if the requirements of 38 U.S.C. § 1116 and 38 C.F.R. § 3.307 (a)(6)(iii) are met, even though there is no record of that disease during service, provided that the rebuttable presumption provisions of 38 U.S.C. § 1113 and 38 C.F.R. § 3.307 (d) are also satisfied. 38 C.F.R. § 3.309 (e). A Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to herbicides, unless there is affirmative evidence to establish that the Veteran was not exposed to herbicides during that service. Service in the Republic of Vietnam includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 U.S.C. § 1116 (f); 38 C.F.R. § 3.307 (a)(6)(iii). The list of presumptive diseases for exposure to herbicides includes ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal’s angina.). See 38 C.F.R. § 3.309 (e). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury; or, any increase in severity of a nonservice-connected disease or injury which is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310(a)-(b). In order to prevail on the theory of secondary service connection, there must be evidence of (1) a current disability, (2) a service-connected disability, and (3) a nexus, or link, between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for a cardiovascular disorder, to include as due to diabetes mellitus, type II The Appellant contends that the Veteran’s cardiovascular disorder was related to herbicide exposure during service, to include as due to diabetes mellitus, type II. The Veteran served in Vietnam and is service connected for diabetes mellitus, type II. An April 2012 private treatment note indicated that the Veteran’s pre-operative clinical evaluation showed unstable angina (60 days). The Veteran underwent left cardiac catheterization, followed by percutaneous transluminal coronary angioplasty (PTCA) for in-stent stenosis. A May 2012 private computed tomography (CT) scan revealed coronary artery atherosclerosis. A related echocardiogram showed left ventricular ejection fraction that was 50 percent; impaired relaxation of the left ventricular diastolic filling; mild mitral valve regurgitation; mild tricuspid regurgitation; and mildly elevated right ventricular systolic pressure. The Board concludes that the Veteran’s cardiovascular disorder, variously diagnosed as unstable angina and coronary artery atherosclerosis was diagnosed after separation. Pursuant to 38 C.F.R. § 3.309(e), unstable angina and atherosclerotic cardiovascular disease are included among the list of diseases in which service connection is presumed if the Veteran served in Vietnam and was diagnosed with any of the specified diseases, at any time after separation. The disorder also manifested to a compensable degree during his lifetime. See 38 C.F.R. § 4.104, Diagnostic Code 7005. In light of the foregoing, the Board is satisfied that the criteria for the establishment of presumptive service connection for a cardiovascular disorder, have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.307, 3.309(e). 2. Entitlement to service connection for a renal disorder, to include as secondary to diabetes mellitus, type II The Appellant contends that the Veteran’s renal disorder was related to herbicide exposure during service, to include as due to diabetes mellitus, type II. The Veteran served in Vietnam and is service connected for diabetes mellitus, type II. March 2006 and August 2007 private Diabetes Herbicide Presumption Physician’s Statements indicated that the Veteran was diagnosed with diabetes mellitus, type II, adult onset. The physician noted that the Veteran’s diabetes mellitus required treatment with medication and a restricted diet. In the physician’s judgment, the Veteran had renal complications that were directly due to diabetes mellitus. An October 2010 VA treatment record indicated that the Veteran was status-post liver transplant and complained of polyuria. There was no evidence of renal bruit. A September 2011 private magnetic resonance imagining (MRI) showed a new mass adjacent to the medial aspect of the left kidney measuring 3.8 x 4.4 cm. The mass invaded the kidney and caused moderate left-sided hydronephrosis. There was evidence of a cyst on the right kidney. The right kidney enhanced normally without evidence of hydronephrosis. A January 2012 private treatment note listed the Veteran’s medical history of diabetes mellitus insulin therapy. A May 2012 MRI showed an unchanged 5 mm simple cyst in the lower pole of the right kidney; the left kidney contained a few tiny simple renal cysts. In a March 2015 VA addendum medical opinion, the examiner opined that the Veteran’s diabetes mellitus did not have renal side effects, nor aggravated any renal problems beyond their normal progression. In a March 2018 addendum medical opinion, the examiner rendered the clinical assessment that the Veteran had an elevated creatinine level due to hepatorenal syndrome, not due to his diabetes mellitus. The examiner explained that patients with advanced liver disease often develop portal hypertension leading to arterial vasodilation causing hemodynamic changes and the decline of renal function. The examiner explained that the Veteran’s February 2012 renal function laboratory results were albumin/creatinine ratio (M-alb/cr) of 3.5 (<30 is normal) and HgA1c of 4.6 percent. The examiner expounded on the fact that in March 2012, the Veteran’s creatinine level was 1.32 and his estimated glomerular filtration rate (eGFR) level was 54. The examiner added that the Veteran’s kidneys did not spill major microalbumin levels as seen in individuals with diabetes mellitus neuropathy. The examiner expounded on the fact that the Veteran had a decreased albumin level due to his liver disease and that in March 2010, after his 2009 liver transplant, the Veteran’s M-alb/cr ratio was still low at 3.8. The examiner further explained that it is less likely as not that the Veteran’s renal disorder was caused by or aggravated by his diabetes mellitus. The March 2018 VA examiner further opined that the March 2006 and August 2007 Diabetes Herbicide Presumption Physician’s Statements were “less than truthful when the provider reported that the Veteran suffered from a renal disorder as secondary to diabetes mellitus”. The March 2018 VA examiner explained that in December 2005, the Veteran had normal kidney function and well-controlled HgAIc. The examiner added that in March 2006, the Veteran was seen at the Savannah Diabetic Clinic, was not prescribed insulin, but was prescribed metformin 500 mg twice a day (a relatively low dose) and did not have renal disease, but had pre-existing hypertension. The examiner noted that the Veteran had normal renal function and was not prescribed insulin in July 2007. The examiner ultimately concluded that the Veteran did not suffer from a renal disorder caused by or aggravated by his diabetes mellitus in 2006 or 2007. In a July 2018 private medical opinion, Dr. R. F., a transplant hepatologist that treated the Veteran before his death, noted that the Veteran underwent a liver transplant in 2009. Dr. R. F. rendered the clinical assessment that prior to his liver transplant, the Veteran had diabetes which “certainly contributed to his kidney disease”. In Dr. R. F.’s judgement, the Veteran clearly had diabetes as an underlying medical condition that is well known in the medical field to cause kidney disease. There is both positive and negative medical opinion evidence regarding the etiology of the Veteran’s renal disorder. Resolving reasonable doubt in favor of the Veteran, the Board finds that secondary service connection for a renal disorder due to diabetes mellitus is warranted. REASONS FOR REMAND 3. Entitlement to service connection for a visual disorder, to include as secondary to diabetes mellitus, type II is remanded. In December 2017, the Board remanded the case for additional development, to include an addendum medical opinion discussing the relationship between the Veteran’s visual disorder and diabetes mellitus. The examiner was asked to opine on whether it is at least as likely as not (i.e., at least a probability of 50 percent or greater) that the Veteran’s diagnosed visual disorder (nuclear sclerosis and cataracts) was caused by or aggravated by his diabetes mellitus. In the March 2018 VA addendum opinion, the examiner only discussed whether the Veteran’s visual disorder was caused by his diabetes mellitus and did not discuss aggravation. As such, an addendum opinion is needed to decide the appeal. See Stegall v. West, 11 Vet. App. 268 (1998). The matter is REMANDED for the following action: 1. Provide the Veteran’s VA records, and a copy of this remand to the VA optometrist (O.D.) who provided the March 2018 opinion. If the original optometrist is not available, the records should be made available to another VA optometrist (O.D.) with appropriate expertise as to the medical issues for the required opinion. A notation to the effect that a complete record review took place should be included in the report. The optometrist must provide an addendum opinion as to whether it is at least as likely as not that the Veteran’s diabetes mellitus AGGRAVATED his visual disorder beyond natural progression. If aggravation occurred, the optometrist should quantify, if possible, the extent to which the disability was aggravated. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Taylor, Associate Counsel